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/// _ ),I;- Itis - <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS - 1 ! �L B V l��° Vi I ! G ' /� jai <br /> )CITY/ZIP I_.L n E7 I Zj'2.,f f. 7 <br /> CROSS STREET ��h:1�) j 17; via APN C� U L I�•, <br /> PARCEL:SIZE �7��±��r, C <br /> OWNER NAME ! /�U a, LCJ�`7 F��-r / V)0(.( L Lei �lZl�< � L� ' PHONE �/ <br /> OWNER ADDRESS T(L t c%,- I C CITY/STATE/ZIP LG "[`tC,L.Z <br /> CONTRACTOR tie l Vy r7 PHONE `7 7 - 17 c-� <br /> CONTRACTOR ADDRESS //`� CITY/STATE/ZIP 1 !'A{�� �G C �7 i^iL- <br /> LICENSE C-42 I C-36 OTHER /A NUMBER t EXPIRATION DATE <br /> WATER TABLE DEPTH: �^�) ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION EPAIR/ADDITION ti ENGINEER DESIGNED/ALTE@NATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 11 RESIDENCE COMMERCIAL 11 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG - CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> LIFT STATION SIZE I 14TYPE OFP U;: '6k PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH _ ft LENGTH _ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH _ ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE� �nJt-✓�_ DATE 12 <br /> 0. <br /> rJ <br /> J0 <br /> N . / OAf/y M <br /> DEPARTMENT USEONLy <br /> Application Accepted Bye Date Area "! Employee ID# � <br /> Final Inspection By 0/ !� N + Date Ll SPECIAL PERMIT -Approved by <br /> Character of Soil to Depth of 3 Ft:_ I P S p So' Character: _ <br /> COMMENTS 6115�eL_c lit& !:540o7637 <br /> Alk FtzloR. ro IAU.A-V / <br /> -2_,4'/L" <br /> PE SC Received Check#/ Amount Permit/ <br /> 4[: <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 2 Qb -3 <br /> 744« <br /> L �'r -le �f�a r--e•(/, vfi) <br /> 42-01 6NSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24;12 <br />